Request for Redetermination of Medicare Prescription Drug Denial

Because we at Blue Medicare Advantage denied your request for coverage of (or payment for) a prescription drug, you have the right to ask us for a redetermination (appeal) of our decision. You have 60 days from the date of our Notice of Denial of Medicare Prescription Drug Coverage to ask us for a redetermination. This form may be sent to us by mail or fax:

Address:
Appeals and Grievances requests
PO Box 8494
St. Louis, MO 63132
Fax Number:
1-877-549-1746


Who May Make a Request:  Your prescriber may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. Contact us to learn how to name a representative.

Enrollee's Information

 
* Enrollee's Name: * Date of Birth:
* Address 1:
Address 2:
* City:    * State:      * Zip:  
Phone:
* Plan ID Number:

Complete the following section ONLY if the person making this request is not the enrollee

 
Requestor's Name:
Relationship To Enrollee:
Address 1:
Address 2:
City:    State:      Zip:  
Phone:
Representation documentation for appeal requests made by someone other than enrollee or the enrollee’s prescriber:
Attach documentation showing the authority to represent the enrollee (a completed Authorization of Representation Form CMS-1696 or a written equivalent) if it was not submitted at the coverage determination level. For more information on appointing a representative, contact your plan or 1-800-Medicare.

Prescription drug you are requesting

 
* Name Of Drug:  * Strength/Quantity/Dose: 
Have you purchased the drug pending appeal? 
If "Yes":
Date Purchased:       Amount Paid:  (attach copy of receipt)
Name and Telephone Number of Pharmacy: 

Prescriber's Information

* Prescriber's Name: 
* Address 1: 
Address 2: 
* City:     * State:      * Zip:  
* Office Phone:    Office Fax:   
* Office Contact Person: 
Important Note: Expedited Decisions

If you or your prescriber believe that waiting 7 days for a standard decision could seriously harm your life, health, or ability to regain maximum function, you can ask for an expedited (fast) decision. If your prescriber indicates that waiting 7 days could seriously harm your health, we will automatically give you a decision within 72 hours. If you do not obtain your prescriber's support for an expedited appeal, we will decide if your case requires a fast decision. You cannot request an expedited appeal if you are asking us to pay you back for a drug you already received.

CHECK THIS BOX IF YOU BELIEVE YOU NEED A DECISION WITHIN 72 HOURS

If you have a supporting statement from your prescriber, attach it to this request.

* Please explain your reasons for appealing in the box below.  Attach additional pages, if necessary. Attach any additional information you believe may help your case, such as a statement from your prescriber and relevant medical records. You may want to refer to the explanation we provided in the Notice of Denial of Medicare Prescription Drug Coverage.

* Signature of person requesting the coverage redetermination (the enrollee, or the enrollee's prescriber or representative):

   * Date:

Y0126_19-556_ITKC - Last updated 12/20/2018